Archive for the ‘US policy’Category

The US health care non-system

I spent much of yesterday thinking about the past, present, and future of the American health care system. I’ve largely chosen classes with an international or methodological focus so this was a bit of a departure from my normal fare. In one day I finished up some readings on health reform, wrote a brief paper speculating on what US healthcare will look like in 2030, attended a talk by Uwe Reinhardt largely based on this paper (PDF), and went to a three hour lecture on US health care (part of a class on the economics of the US welfare state).

It’s a mammoth subject, and there are many bloggers who write exclusively about domestic health policy — the guys at the Incidental Economist have smart stuff to say on it every day. There’s so much to be said and done even on the somewhat narrowed subject of the Affordable Care Act (ie, “ObamaCare”).

But that’s not what keeps popping into my head.What keeps getting reinforced is how our system really isn’t a system at all, but a weird conglomeration of lots of different approaches for various fragments of our society that emerged for quirky historical and political reasons. I found this description — from a report comparing various industrialized countries’ systems — humorously understated: “The U.S. does not have a ‘health system,’ but rather a variety of private and public institutions and programs that regulate, finance, and deliver care.” (source)

Paul Starr’s classic Social Transformation of American Medicine is a good start for trying to understand how we got to the ‘variety’ we have today.  The end result is that it doesn’t serve very many people well at all. The US is a great place to get the most advanced care if you can afford it, but even then you’re going to pay a lot more for it. For the non-wealthy the expenses are amplified and we end up rationing care by ability to pay. By pretty much every standard other than innovation (ie, including the delivery of that innovation to those who really need it, not just those who can pay) the US falls dreadfully short. We get poor life expectancy, magnified inequalities, and spending that’s roughly twice as much per person as in any other wealthy country.

Ironically, whether the Affordable Care Act goes into effect in 2014 depends largely on whether Obama gets reelected, and whether Obama gets reelected or not depends largely on what the unemployment rate does between now and November. So the future of the US health system depends in a very real way on fluctuations in the economy over the next eight months, and no one really understand that well at all.

If you’re just looking at the trajectory of the American health system the ACA is a major reform, even a fundamental one.  It will do (and has already started to do) a lot of good things, but I’m skeptical that it will do all that much to fix costs or shift our focus to public health —prevention over treatment. There are a lot of good small fixes in there, but nothing revolutionary when you compare us to other countries.

And this is why I find domestic health policy profoundly depressing. It’s why I’ve chosen to focus more on international health than domestic politics. In international health I think the prospects for witnessing and contributing to massive, heartening, orders-of-magnitude positive change in my professional lifetime are quite real. On US health policy, I’m less optimistic. My friend and classmate Jesse Singal wrote a description of the US health system — in the context of astonishingly ridiculous remarks by some conservatives on contraception — that I think about sums it up:  “…our medical system is an octopus riding a donkey riding a skateboard into a sadness quarry.”

01

03 2012

1WTC

After years of delays, the new One World Trade Center is going up fast. I took this picture just one block from my office:

Business Week has an interesting account of how the redevelopment of the site was debated and negotiated over the last 10 years. And of course the next month will see a flurry of writing and coverage related to the ten-year anniversary of 9/11. Ten years ago I was a high school student in Arkansas and New York City felt very far away. My mom had been visiting her sister in DC and was flying home that morning. I needed to see the orthodontist in Little Rock so my dad and I drove down together to pick her up at the airport, and heard the first reports on the radio on the drive down. Nobody in my family flew very often so everyone knew she’d be flying — my parents spent the rest of the day contacting people to assure them my mom hadn’t been on one of the flights. I missed all the emotional reactions of learning at school that many people recount, but that afternoon I worked my normal shift at my town’s Kroger grocery store as we had a small rush of people buying supplies, and listened to people talking about lining up to get gas, just in case.

07

08 2011

New books

… that I wish I had time to read:

1) Laurie Garrett’s first book since Betrayal of Trust (2000) is I Heard the Sirens Scream, which takes on 9/11, the anthrax attacks, and the US response to both. I’m most interested in the discussion of “the bizarre chemistry of The Plume that rose from the burning crushed World Trade center for four months.” Alanna Shaikh interviews Garrett about the book in UN Dispatch.

2) The Other Barack, though it sounds depressing.

3) The Invention of Brownstone Brooklyn: Gentrification and the Search for Authenticity in Postwar New York. A review:

By 1982, Osman writes, the number of hardware stores in Park Slope was more than three times the per-capita average in the rest of the city, and surveys indicated that a majority of Park Slope residents were undertaking most improvements themselves. In the current age of multimillion-dollar brownstone sales, it’s easy to forget the more modest roots of these neighborhoods….New, politically savvy residents sometimes found common cause with local residents in lobbying for services and opposing large-scale development. In 1975, the Fort Greene Non-Profit Improvement Council was powerful enough to obtain a court injunction halting study of the construction of a new Giants Stadium on the Atlantic Terminal site. Such coalitions, however, don’t always hold together….

Sounds interesting throughout, especially now that I’ve been to Brooklyn. Yes, before this summer I had never really ventured outside of Manhattan on my few visits to New York. Also, the question of gentrification is one of those things I used to think was simple, when I first read of it. Surprisingly (or not?) it was talking through those issues in DC with several friends who are urban planners that made me realize that there generally aren’t easy answers to any question involving old and new residents and changing economic fortunes in a neighborhood.

Not #4: After reading J’s review, I think I’ll pass on Inside the Everyday Lives of Development Workers.

01

08 2011

The view from my window

Andrew Sullivan’s Daily Dish is one of my favorite blogs. One feature I’ve grown to love is the daily “View from your window,” and today he featured a shot I took on Sunday looking out my apartment window here in NYC:

13

07 2011

NYC mystery of the day: trash collection

I keep hearing complaints from both New York residents and visitors alike that the city smells. You get used to it pretty fast, but it’s true — especially during the summer.

In the two other cities I’ve lived in (Washington, DC and Baltimore) I would put the trash out in a specially marked bin or garbage can for pick-up. My apartment in the East Village has a designated bin on the sidewalk, but we seem to be an exception rather than the rule. Most people just stack their trash bags on the sidewalks, like so:

This contributes to the smell, and probably to the rat problem as well. So why doesn’t New York require trash to be placed in bins like at least some other American cities?

This brief history of trash collection in NYC is fascinating, but it doesn’t really offer an answer. So I’m stumped for now, but my best guess is that sidewalk and building entryway space are at such a premium that space-consuming trash bins have never been popular. If you have another explanation I’d be happy to hear it.

12

07 2011

Equality in NY

I had this post saved as a draft for the last week or so — oops:

——

It’s a great summer to be in New York City. I was watching the news on same sex marriage pretty closely, and as soon as the religious exemptions amendment passed — signalling that passage of the bill itself was just a matter of time — bloggers started noting that crowds were gathering in front of the Stonewall Inn in Greenwich Village. I live about a mile east of there in the East Village, so I headed out immediately to be there at the historic moment.

This may come as a surprise for gay rights advocates — or for pretty much anyone who didn’t go to an extremely conservative university — but I hadn’t heard of the Stonewall Riots until a year or two ago. The Stonewall has been on my long list of historical sights to see in New York but I hadn’t been there yet, and what better time to visit than on this historic occasion?

Sure enough, there was a big crowd gathered and quite a few media outlets on hand. I snapped this shot of an endearing older couple being interviewed:

And here are two NYPD officers doing crowd control, chatting amiably with the celebrants:

While the pace of change can often seem glacial for those eagerly advocating (as they rightly should) for justice now, it struck me that on a grander scale this progress has come impressively fast. Just a little over 40 years ago — half a lifetime — the police were systematically oppressing and raiding the few gay establishments in New York. Their actions were hardly inconsistent with popular will either, as there really was no gay rights movement yet. And now, in 2011, there the officers were, guarding a peaceful and spontaneous celebration by New Yorkers — male and female, gay and straight — of marriage equality, something that was probably inconceivable to the Stonewall rioters. Yes, the law is not yet perfect and we still have far to go, but for that night it felt right to pause and reflect on just how far we’ve come.

11

07 2011

Advice not to trust

Yesterday morning I came across the gentleman pictured below in New York’s Union Square. I’ve been meaning to take more pictures of “things you only see in NYC” — a category which generally consists of extremes of pets and fashion — but I think this deserves its own post:

He was either selling or trying to give away copies of a book titled Uropathy: The Most Powerful Holistic Therapy by one Martin Lara. Since the review of Uropathy on Amazon.com is from the Village Voice, I assume that the evangelist was either Lara or one of his disciples. The review:

Vitamin Pee! Urine is a natural remedy, so raise a glass! That’s what alternative therapist Martin Lara wants everyone to do. In his Uropathy: The Most Powerful Holistic Therapy, pee’s the ultimate cure-all. Gagging aside, it’s not so unconventional: former Indian prime minister Morarji Desai guzzled ounces each morning, observing an ancient Hindu practice. Lara learned about it 11 years ago, when the self-taught therapist he’s never studied traditional medicine became disenchanted with science’s inability to cure his ailments. Since then he’s lectured to thousands. Not any pee will do it must be your own, which Lara says is a nontoxic biofeedback stimulator that boosts immunity by activating the lymphatic system, thus restoring the body to an internally balanced state of health. Dosages range from a few drops of Lara’s “Ultimate Universal Remedy” an elixir of water, urine, and white rum to several ounces for serious conditions like cancer, dysentery, or Alzheimer’s. Of course, not everyone is ready for this leap of faith. On his Web site Lara argues against obsessing over taste and smell: “Urine is a sample of what is flowing through your veins and repulsive urine should be a motivation to improve the internal conditions, rather than an excuse for not using Uropathy.” — The Village Voice

He was quite earnest. I didn’t engage him in conversation because two other passersby were already talking to him. A girl was explaining that urine is what your kidneys decide your body doesn’t need. But she wasn’t just explaining it, she was disgusted, and angry. His response was similar to a major defense of homeopathic medicine, that the “toxin makes the remedy” (or something like that). The girl got exasperated and left with her friend, and you could hear her ranting as she walked away. I chose not to continue the conversation because I was on my way to meet friends, but in hindsight I wish I had stayed because there are some questions I don’t have the answers to:

  • How often does he talk publicly about this? What does he do for a living? Ie, is this it, or does he have a boring day job and this is his true passion?
  • Does he feel that drinking urine has cured whatever health problems that he originally sought help for? (I would guess so.)
  • Why does he think drinking urine has not been more widely adopted?
  • Does he think that his approach (especially the t-shirt and public ‘evangelism’) is the most effective way to spread his message? I would guess he enjoys the attention on some level, but also promotes his beliefs through other, more effective channels.
  • What are the typical reactions he gets? How many people stay and talk with him at length, and of those how many eventually adopt his therapy?
  • I’d like to talk a bit about Western medicine. Not necessarily the biomedical interventions we favor, but the scientific process by which we (ideally) establish that a practice is beneficial. Does he think urine therapy could be tested by a randomized controlled trial? If not, why not?
  • If the passerby had stuck around: why did she choose to argue with him? Did she really think that a guy wearing a bright yellow “Drink Urine” t-shirt in Union Square was likely to change his mind? And for the man himself: how common is her argumentative reaction?

I think a natural first reaction to something this out of the ordinary is laughter or mockery, or the assumption that he’s clinically insane. On further thought, what he believes — in factual support and argumentative method, if not in substance — isn’t that different from much of alternative medicine, and his methods have been widely adopted by many mainstream religions and social movements as well as less-respected ‘fringe’ beliefs. If those are both true, why isn’t his belief more widely adopted? Is it just too taboo?

I think I could have learned valuable things about the mixture of reason and emotion and belief that guide human choices if I had stayed and asked some of these questions. I don’t think I’ll change his mind, but I plan to look for him if I’m ever strolling through Union Square on a weekend again.

(Note: evidently “urine therapy” is a thing. The Wikipedia page starts with “In alternative medicine…” — never a good sign.)

26

06 2011

Monday Miscellany: NYC edition

Two weeks ago I moved to New York City for the summer, so today’s links from around the interwebs are focused on the Big Apple:

21

06 2011

Miscellany: Epidemic City and life expectancy

In 8 days I’ll be done with my first year of graduate studies and will have a chance to write a bit more. I’ve been keeping notes all year on things to write about when I have more time, so I should have no shortage of material! In the meantime, two links to share:

1) Just in time for my summer working with the New York City Department of Health comes Epidemic City: The Politics of Public Health in New York. The Amazon / publisher’s blurb:

The first permanent Board of Health in the United States was created in response to a cholera outbreak in New York City in 1866. By the mid-twentieth century, thanks to landmark achievements in vaccinations, medical data collection, and community health, the NYC Department of Health had become the nation’s gold standard for public health. However, as the city’s population grew in number and diversity, new epidemics emerged, and the department struggled to balance its efforts between the treatment of diseases such as AIDS, multi-drug resistant tuberculosis, and West Nile Virus and the prevention of illness-causing factors like lead paint, heroin addiction, homelessness, smoking, and unhealthy foods. In Epidemic City, historian of public health James Colgrove chronicles the challenges faced by the health department in the four decades following New York City’s mid-twentieth-century peak in public health provision.

This insightful volume draws on archival research and oral histories to examine how the provision of public health has adapted to the competing demands of diverse public needs, public perceptions, and political pressure.

Epidemic City delves beyond a simple narrative of the NYC Department of Health’s decline and rebirth to analyze the perspectives and efforts of the people responsible for the city’s public health from the 1960s to the present. The second half of the twentieth century brought new challenges, such as budget and staffing shortages, and new threats like bioterrorism. Faced with controversies such as needle exchange programs and AIDS reporting, the health department struggled to maintain a delicate balance between its primary focus on illness prevention and the need to ensure public and political support for its activities.

In the past decade, after the 9/11 attacks and bioterrorism scares partially diverted public health efforts from illness prevention to threat response, Mayor Michael Bloomberg and Department of Health Commissioner Thomas Frieden were still able to work together to pass New York’s Clean Indoor Air Act restricting smoking and significant regulations on trans-fats used by restaurants. Because of Bloomberg’s willingness to exert his political clout, both laws passed despite opposition from business owners fearing reduced revenues and activist groups who decried the laws’ infringement upon personal freedoms. This legislation preventative in nature much like the 1960s lead paint laws and the department’s original sanitary code reflects a return to the 19th century roots of public health, when public health measures were often overtly paternalistic. The assertive laws conceived by Frieden and executed by Bloomberg demonstrate how far the mandate of public health can extend when backed by committed government officials.

Epidemic City provides a compelling historical analysis of the individuals and groups tasked with negotiating the fine line between public health and political considerations during the latter half of the twentieth century. By examining the department’s successes and failures during the ambitious social programs of the 1960s, the fiscal crisis of the 1970s, the struggles with poverty and homelessness in the 1980s and 1990s, and in the post-9/11 era, Epidemic City shows how the NYC Department of Health has defined the role and scope of public health services, not only in New York, but for the entire nation.

2) Aaron Carroll at the Incidental Economist writes about the subtleties of life expectancy. His main point is that infant mortality skews life expectancy figures so much that if you’re talking about end-of-life expectations for adults who have already passed those (historically) most perilous times as a youngster, you really need to look at different data altogether.

The blue points on the graph below show life expectancy for all races in the US at birth, while the red line shows life expectancy amongst those who have reached the age of 65. Ie, if you’re a 65-year-old who wants to know your chances of dying (on average!) in a certain period of time, it’s best to consult a more complete life table rather than life expectancy at birth, because you’ve already dodged the bullet for 65 years.

(from the Incidental Economist)

from Baltimore to Central America via David Simon's imagination

David Simon, creator of The Wire and newly minted MacArthur Fellow, is interviewed by Bill Moyers in Guernica. It’s one of the best things I’ve read in quite a while.

David Simon: You talk honestly with some of the veteran and smarter detectives in Baltimore, the guys who have given their career to the drug war, including, for example, Ed Burns, who was a drug warrior for twenty years, and they’ll tell you, this war’s lost. This is all over but the shouting and the tragedy and the waste. And yet there isn’t a political leader with the stomach to really assess it for what it is.

Bill Moyers: So whose lives are less and less necessary in America today?

David Simon: Certainly the underclass. There’s a reason they are the underclass. We’re in an era when you don’t need as much mass labor; we are not a manufacturing base. People who built stuff, their lives had some meaning and value because the factories were open. You don’t need them anymore.

When I first moved to Baltimore I avoided watching The Wire for several months because I didn’t want it to color my first impressions, and I’ve still only had time to watch the first season. But based on that alone, The Wire was a work of art, and one that was always risky in terms of commercial success because of the length of its story arcs.

A while back Kottke highlighted Simon’s original pitch for the series (emphasis added):

But more than an exercise is realism for its own sake, the verisimilitude of The Wire exists to serve something larger. In the first story-arc, the episodes begin what would seem to be the straight-forward, albeit protracted, pursuit of a violent drug crew that controls a high-rise housing project. But within a brief span of time, the officers who undertake the pursuit are forced to acknowledge truths about their department, their role, the drug war and the city as a whole. In the end, the cost to all sides begins to suggest not so much the dogged police pursuit of the bad guys, but rather a Greek tragedy. At the end of thirteen episodes, the reward for the viewer — who has been lured all this way by a well-constructed police show — is not the simple gratification of hearing handcuffs click. Instead, the conclusion is something that Euripides or O’Neill might recognize: an America, at every level at war with itself.

And not just with itself. The Guernica interview I quoted from above resonated with me because I had just finished this Economist article on “Central America: the tormented isthmus” which outlines the many ways in which America’s appetites and means result in our internal war being continuously foisted upon other countries.

Nearly all the world’s cocaine is produced in Colombia, Peru and Bolivia. The biggest consumer is the United States, where the wholesale price of a kilo of the stuff, even full of impurities, starts at $12,500. The route to market used to run from Colombia to the tip of Florida, across the Caribbean. But the United States Coast Guard shut down that corridor by the early 1990s, and shipments switched to the Pacific coast of Mexico. Now Mexico, too, has increased the pressure on the traffickers, just as Colombia has done in the south.

Ever supple, the drugs business has sought new premises. Somewhere between 250 and 350 tonnes of cocaine—or almost the whole amount heading for the United States—now pass through Guatemala each year, according to American officials…

The impact has been lethal. Guatemala’s murder rate has doubled in the past decade. In both Guatemala and El Salvador, the rate of killing is higher now than during their civil wars.

The comments on that article led me to this BBC article from April 7, on the drug-fueled violence in Mexico.

This view [that the violence is the result of fighting between rival criminal gangs, a sign of progress in the drug war] was echoed by the head of the US Drug Enforcement Administration, Michele Leonhart, at an international conference in the Mexican City of Cancun on Wednesday.

“It may seem contradictory, but the unfortunate level of violence is a sign of success in the fight against drugs,” the DEA chief said.

And that must also mean that the increasing violence in Central America due to shifts in drug trafficking patterns is truly a sign that we’re winning the future. If this is success, maybe we’d all be better of with failure.

16

04 2011